Anticoagulation Myth Busters

MYTH

“I have decided to put my patient on a NOAC, which one is the best? And at what dose?”

REALITY

“All four currently available NOACs are licensed to treat non-valvular AF. Although there are no head-to-head trials directly comparing the NOACs, a comprehensive systematic review and network meta-analysis (NMA) recently undertaken does provide some guidance as to which NOAC might be preferred in terms of efficacy, safety and cost-effectiveness. As part of the NMA, a wide range of outcomes were evaluated, including stroke/systemic embolism, myocardial infarction, major bleeding and all-cause mortality. Apixaban (5mg bd) was found to be the best intervention across all of these outcomes and edoxaban (60mg od) was ranked second for major bleeding and all-cause mortality. Except for all-cause mortality and MI, outcomes for rivaroxaban (20 mg od) were ranked less highly than those for apixaban (5 mg bd), dabigatran (150 mg bd) and edoxaban (60 mg od).” 1,2

While the findings of the NMA help to inform decision-making, a patient-centred approach should be taken when considering OAC for stroke prevention. Following an informed discussion with the patient regarding the available treatment options, the characteristics to take into account when determining the most appropriate drug and dose include: age, weight, renal function (in the form of calculated creatinine clearance), bleeding risk, previous history of bleeding, history of dyspepsia, history of stroke and need for a compliance aid.

REFERENCES
  1. Lopez-Lopez JA, Sterne JAC, Thom HHZ, Higgins JPT, Hingorani AD, Okoli GN, et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ. 2017;359:j5058.
  2. Sterne JA, Bodalia PN, Bryden PA, Davies PA, Lopez-Lopez JA, Okoli GN, et al. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess. 2017;21(9):1-386.
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